Daoud Surgery and Family Medicine, PC

Available Forms

Child Complete Physical Health History form Complete Physical Health History form Consent for Teleheath Visit Female Complete Physical Health History form Male Complete Physical Health History form Parental Permission Form REGISTRATION INFORMATION FORM

Parental Permission Form

I give permission for

Child's First Name *

Please write your son or daughter's first name in the blank space.

Child's Last name *

Write you son or daughter's last name

my *

Please check the child's relationship to you:

Born on: *

Write child's birth date

to be seen at Daoud Surgery and Family Medicine, PC office. I give permission for the doctor's office to bill my insurance company for any fees that are billed. I understand that I will be responsible for payment if the insurance does not pay the fees charged. I also understand that I am responsible for and co-pays or deductibles that are due at the time of service. I give permission for my child to be seen for future visits as well. By writing my name and date below, it is the same as signing this permission form and will be legally binding as such.

Parent's First Name *

Write in your (parent) first name

Parent's Last Name: *

Write in your (parent) last name

Relationship to child: *

Explain if not the parent how you have legal rights of the child:

Explain how you have legal right of the child

Date signed *

Today's date

* Required field